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Privacy Notice



During your treatment at Western Arkansas Counseling and Guidance Center, it will be helpful for the Center to obtain information regarding any treatment you may have received from previous treating professionals. This will assist our staff in appropriately evaluating your treatment needs and help provide the best quality of care for you. Similarly, should you at any future time receive treatment from a professional caregiver other than through our Center, that caregiver may also request information concerning you from our treatment records. In order for these exchanges of information to occur, your written authorization must be obtained.

Your consent as indicated by your signature on the “Therapy Contract“ allows the Center to use and disclose Protected Health Information internally for purposes of carrying out treatment, payment and health care operations at the Center. These includes such activities as sharing clinical information with members of your treatment team and appropriate others at the Center to conduct assessment and treatment activities, periodically reviewing your treatment plan and progress in treatment, filing your chart in Medical Records following each service event, and carrying out the internal communications necessary for billing purposes.

There are certain circumstances required or permitted by law under which information concerning you and/or your treatment at the Center may be released to appropriate individuals or officials without your consent, authorization or agreement. These include situations involving suspected child abuse or neglect, disclosure necessary to avert potential immediate threat to health and safety to you or others, for purposes of emergency care, when information concerning your treatment or evaluation at the Center is court-ordered and in other specific circumstances which are permitted by law for such disclosure. The Center’s contract with the Arkansas Division of Mental Health Services allows the Center to exchange information with the Arkansas State Hospital for the care of mutual patients without obtaining the written consent of the patient.

Disclosure of information from your chart to your insurance carrier, or other third party payer source, must first be authorized by you in writing. Other uses and disclosures of information concerning your treatment at the Center will be made only upon your written authorization and this authorization may be revoked by you at any time prior to the release of the information. A notice referencing the applicable Federal regulation (42 CFR, Part 2) is included on our authorization form to warn against re-disclosure of information. During the course of your treatment at the Center, you may be contacted by phone or mail to be reminded of appointment times or to discuss other important matters related to your treatment or our services. Also, during treatment and thereafter you may be contacted by phone or mail in order for the Center to learn of your satisfaction with services received or to assess the effectiveness of its services. If you do not wish to be contacted for these purposes the Center will not do so upon your request.

You have other individual rights with respect to the uses and disclosures of protected health information from your file at the Center. These include:

(1) The right to request restrictions on certain uses and disclosures of this information, although the Center is not required to agree to such a restriction.

(2) The right to receive confidential communications of information from your file as well as the right to inspect and make copies of material from your file. The exceptions to this will be materials in your file which the Center has received from other professional caregivers, psychological test protocols and other material exempted by law from access, or information which your therapist believes to have the potential for being misunderstood and/or potentially harmful to you or others if revealed directly to you or your personal representative. Other information in your chart exempted from inspection and copying will include any information obtained from someone other than a health care provider under a promise of confidentiality that would be breached by the disclosure and information temporarily exempted in a research situation. When the request to inspect or make copies of material in your file is denied for any reason, you have the right to request to have the denial reviewed by appropriate staff members at the Center. You may make this request in writing through your primary therapist.

(3) The right to review and amend material in your file with the exceptions of those items mentioned in #2 above or when your record is deemed to be accurate and complete by your primary therapist, his/her clinical supervisor and program director. If material received from a previous caregiver is subsequently amended by that caregiver, the Center, upon official notification of the amendment, will also identically amend its copy of the same subject matter.

(4) The right to be informed when information from your file has been disclosed and the right to receive a paper copy of this notice upon your request.

It is the Center’s duty to maintain the privacy of protected health information in your file and to provide you with notice of its legal duties and privacy practices concerning this information. It is the Center’s further duty to abide by the terms of this privacy notice currently in effect. We reserve the right to change the terms of this notice and to make the new notice effective for all the protected health information we maintain. If changed, you will be provided with a revised notice during your next contact at the Center.

If you believe your rights have been violated you may file a complaint by requesting to do so with any member of your treatment team or other Center staff member. There will be no retaliation by the Center against persons who may file a complaint. If preferred, you may also request to file a complaint through contacting the Director of Child-Family Services, the Director of Adult Programs or the Director of Clinical Services. These individuals may be reached at the Primary Service Center in Fort Smith at 479.452.6650. Upon contacting these persons, you will be given information concerning the steps to be followed in accessing the Center’s grievance procedure.


Click here to download a copy of this privacy notice.

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